Ask The Urologist Anything (Dr Michael Rotman)

[DrRotman]

Dr Rotman
Do you ever prescribe finastride for hairloss prevention for patients on TRT? maybe use it first three days after injection since that is when DHT is at its highest?
Thanks in advance

Hi Andre,

I do not generally prescribe finasteride for hair loss unless the patient has a strong family history of male pattern baldness and requests it. Finasteride can impact libido, fertility and erectile function with some patients stating they continue to have these side effects even when stopping the medication. I am not sure how it would work if just used immediately after injection. I do recommend patients use Rogaine and ketoconazole shampoo if hair loss is beginning to help prevent further loss. That being said, I have many patients whom I see for all urological reasons that take finasteride for hair loss and do see hair growth.

 

[Gamnc]

Just curious. I take .8 ML of Testosterone Cyp 200 per week(.4 every 3.5 days). With a body weight of 220 how high would you expect mylevels to climb. I was on Testopel pellets till a few weeks ago, and would makeit into the 500 range with 12 pellets. Iwas hoping to push this up into the 800 to 1000 range.

 

[wrldzfstst]

Good morning,

Doctor, do you recommend TrixMix to your ED patients? I am on TRT and prescribed Cialis and still erections are not hard enough to sustain intercourse. I suspect there isn't much history on the downsides medium-term but wanted your thoughts on it if possible.

Thank you.

 

[DrRotman]

Just curious. I take .8 ML of Testosterone Cyp 200 per week(.4 every 3.5 days). With a body weight of 220 how high would you expect mylevels to climb. I was on Testopel pellets till a few weeks ago, and would makeit into the 500 range with 12 pellets. Iwas hoping to push this up into the 800 to 1000 range.

There is no definitive way to tell your trough level just based on dose and weight. I would not be so concerned with your level as much as your overall wellbeing. If you are doing well on the dose and don't have any adverse effects , I would not concern myself.

 

[DrRotman]

Good morning,

Doctor, do you recommend TrixMix to your ED patients? I am on TRT and prescribed Cialis and still erections are not hard enough to sustain intercourse. I suspect there isn't much history on the downsides medium-term but wanted your thoughts on it if possible.

Thank you.

yes, I do use Trimix for ED but only after all oral options have been exhausted. Penile injections do cause scarring which can lead to further deterioration. I would try other oral options and consider a penile vascular exam as well.

 

[johndoesmith]

There is no definitive way to tell your trough level just based on dose and weight. I would not be so concerned with your level as much as your overall wellbeing. If you are doing well on the dose and don't have any adverse effects , I would not concern myself.

Why is that?

I know that TRT dose has very little to do with weight, but most drugs are dosed based on weight, why is this different?

I know about SHBG level having a major role in a guy's response to exogenous testosterone but let's leave that out for this question.

I can't articulate a reason as to why weight doesn't have anything to do with a guy's response to testosterone in terms of blood levels.

 

[zojo360]

Dr.
I have had my prolactin levels tested over the years and has always come back slightly above high. My average is 17.2 with a range of 4-15. All other tests for pituitary abnormalities are negative. The only thing I "feel" is a somewhat lowered libido as in not always one to initiate sexual encounters. Once sex or intimacy is introduced, no other problems are a factor.
I have 2 questions
1) Can this higher prolactin also affect motivation or drive in general?
2) How effective is cabergoline for this treatment, how fast does it work and what percentage of reduction can be expected?
Thank you.

 

[Dr Justin Saya MD]

Why is that?

I know that TRT dose has very little to do with weight, but most drugs are dosed based on weight, why is this different?

I'll jump in on this one and Dr Rotman can expand if he wishes, but this is a common misconception. Most drugs are NOT dosed based on body weight, aside from the pediatric setting.

 

[johndoesmith]

I'll jump in on this one and Dr Rotman can expand if he wishes, but this is a common misconception. Most drugs are NOT dosed based on body weight, aside from the pediatric setting.

Heh. You know, I have no idea where I even had that idea from. It just "felt" right in my head, but thinking about it, I can't think of a drug dosed on weight off the top of my head in adults.

Wow, shows you how powerful biases are.

I guess I was imagining alcohol for some reason, although it is 5 o'clock here

So how much of an effect does weight have on testosterone dose assuming SHBG and BF% is the same in a 2 guys A.150 vs B.280?

 

[Dr Justin Saya MD]

So how much of an effect does weight have on testosterone dose assuming SHBG and BF% is the same in a 2 guys A.150 vs B.280?

To be honest, somewhat counterintuitively, weight has virtually no impact on predicting dosage or response to TRT. I've seen 250 pound ex-bodybuilders require a lower T dosage than 135 pound yoga instructors and vice versa. Body fat percentage does help to predict aromatization, however.

 

[johndoesmith]

To be honest, somewhat counterintuitively, weight has virtually no impact on predicting dosage or response to TRT. I've seen 250 pound ex-bodybuilders require a lower T dosage than 135 pound yoga instructors and vice versa. Body fat percentage does help to predict aromatization, however.

Is there any explanation for this? I cannot think of one myself.

I assume it has to do with testosterone level being impacted more by individual metabolization and SHBG level than weight or even due to the way it's distributed in serum?

 

[Dr Justin Saya MD]

Is there any explanation for this? I cannot think of one myself.

I assume it has to do with testosterone level being impacted more by individual metabolization and SHBG level than weight or even due to the way it's distributed in serum?

Yes, many other variables of more significance at play.

 

[Dr Justin Saya MD]

Let's give this thread back to Dr Rotman

A new thread can be started if there are more questions on the current discussion.

 

[DrRotman]

Dr.
I have had my prolactin levels tested over the years and has always come back slightly above high. My average is 17.2 with a range of 4-15. All other tests for pituitary abnormalities are negative. The only thing I "feel" is a somewhat lowered libido as in not always one to initiate sexual encounters. Once sex or intimacy is introduced, no other problems are a factor.
I have 2 questions
1) Can this higher prolactin also affect motivation or drive in general?
2) How effective is cabergoline for this treatment, how fast does it work and what percentage of reduction can be expected?
Thank you.

In my experience many patients have slightly elevated prolactin levels which upon consultation with endocrinologists do not require a work up. When it is much higher , a workup is indicated. The level you have would not give you any symptoms not should you use cabergoline for this level.

 

[DrRotman]

Let's give this thread back to Dr Rotman

A new thread can be started if there are more questions on the current discussion.

Thank you Dr Saya for answering this question. I agree with all of your answers. We are learning all the time about the variances of TRT as it still is an evolving field. Lots of good questions here.

 

[johndoesmith]

Dr. Rotman, what do you think of the prostate saturation theory and it's validity?

The prostate saturation model suggests that the androgen receptor (AR) is saturated at serum testosterone levels of 150–200 ng/dl, and that additional serum testosterone above this level has limited, if any, effects within the prostate. Indeed, studies in the modern era of PSA assessments indicate that TST does not affect prostate size, intraprostatic testosterone levels, or prostate-cancer progression, provided the baseline serum testosterone level is greater than this AR saturation point

http://www.nature.com/nrurol/journal/v11/n9/abs/nrurol.2014.163.html

In other words, there is a limit to the ability of androgens to stimulate prostate growth, whether benign or malignant. This explains why serum prostate-specific antigen (PSA) does not correlate with serum T concentrations in a normal population, [15] yet PSA declines dramatically with experimental androgen deprivation in healthy volunteers, [16] and why 5 alpha reductase inhibitors that produce castrate-level dihydrotestosterone (DHT) concentrations reduce serum PSA by approximately half. [17] Yet administration of supraphysiological T doses to healthy volunteers for as long as 9 months does not result in increased PSA or prostate volume.

http://www.ajandrology.com/article....ssue=2;spage=206;epage=211;aulast=Morgentaler

 

[DrRotman]

Dr. Rotman, what do you think of the prostate saturation theory and it's validity?



http://www.nature.com/nrurol/journal/v11/n9/abs/nrurol.2014.163.html




http://www.ajandrology.com/article....ssue=2;spage=206;epage=211;aulast=Morgentaler

I believe it's valid and Baylor University has also published an article on this. I take this into consideration when I follow PSA tests in patients on TRT.

 

[johndoesmith]

I believe it's valid and Baylor University has also published an article on this. I take this into consideration when I follow PSA tests in patients on TRT.

Thank you Dr. Rotman! It's great to hear that from a doctor who is experienced with TRT(one who knows what E2 is) and a urologist!

What do you think of the free hormone hypothesis and the free hormone transport hypothesis regarding testosterone?

Studies and information I've found indicate that the free hormone hypothesis applies to testosterone, yet many men post here with low total testosterone and mid range free testosterone yet are still symptomatic?

Do you believe this to be due to the SHBG receptor or is it due to something else?

 

[DrRotman]

Thank you Dr. Rotman! It's great to hear that from a doctor who is experienced with TRT(one who knows what E2 is) and a urologist!

What do you think of the free hormone hypothesis and the free hormone transport hypothesis regarding testosterone?

Studies and information I've found indicate that the free hormone hypothesis applies to testosterone, yet many men post here with low total testosterone and mid range free testosterone yet are still symptomatic?

Do you believe this to be due to the SHBG receptor or is it due to something else?

i don't really use free T much in practice anymore and have completely adopted bioavailable T which is a much more accurate measure.

 

[Holden]

Dr Rotman,

What's your view and experience with testicular pain/discomfort being related to TRT? Ive been on TRT pellets for 5 months and about 2 months ago having some pain and discomfort on and off. In describing the situation, many online folks think it must be atrophy and I should take HCG. However, I've seen 2 Urologists and 1 Endo in person, and all 3 think it's more likely due to either back misalignment caused by working out, or just that somehow that area has become inflamed and often times it takes time to return to normal --prescribed Daypro for 30 days. Prostate normal 0.46, urine culture normal, testicular ultrasound normal. Do you come across testicular pain much in your practice and if so, does HCG cure it, or is it more often related to something other than atrophy from TRT?